- The Two Domains at a Glance
- Domain 1: Refractive / Sensory Processes / Oculomotor Processes
- Domain 2: Normal Health / Disease / Trauma
- The Content Matrix: Four Task Dimensions, Not Four More Domains
- How the Domains Appear on Test Day
- Sequencing Your Preparation by Domain
- Registration, Fees and Scoring Context
- Frequently Asked Questions
The Patient Assessment & Management Exam is Part II of the National Board of Examiners in Optometry (NBEO) sequence. It is the entry-to-profession licensure examination that tests whether you can work through a patient case, not merely recall isolated facts. Understanding how the content is carved up is the first step to studying efficiently. This guide walks through both content areas, explains how the separate content matrix overlays them, and shows how to translate the weights into a study plan. If you want to put the domains into practice right away, the PAM practice test site is built around this same structure.
- PAM's outline has two domains: Refractive / Sensory Processes / Oculomotor Processes (30-40%) and Normal Health / Disease / Trauma (60-70%).
- The matrix's four task dimensions (Diagnosis 26-34%, Treatment / Management 40-57%, and others) intersect the domains; they are not extra domains.
- The exam is 350 questions in two 175-question sessions, with about 120 TMOD items embedded within the 350.
- NBEO's Scoring & Reporting page says scores above 300 pass on a 100-900 scale, equated across forms.
The Two Domains at a Glance
NBEO's current Part II PAM Content Outline divides the examination into two top-level condition and content areas. The outline linked on optometry.org carries a May 8, 2026 filename date; that is a file date, not an announced change to the exam edition, so treat the structure below as the current published blueprint while still checking NBEO's pages before you register.
| Domain | Weight | Character of the content |
|---|---|---|
| Domain 1: Refractive / Sensory Processes / Oculomotor Processes | 30-40% | Functional visual system: refractive state, binocular vision, accommodation, vergence and eye movement |
| Domain 2: Normal Health / Disease / Trauma | 60-70% | Ocular and systemic health: normal findings, pathology, inflammation, infection and injury |
Notice that the ranges overlap in how they can sum: a given form might sit at 35% and 65%, or 30% and 70%. NBEO publishes ranges, not fixed counts, so do not build a plan around an exact number of questions per domain. Plan around proportion instead: roughly one-third functional vision, roughly two-thirds health and disease.
Domain 1: Refractive / Sensory Processes / Oculomotor Processes
This domain covers the optical and neurological machinery that turns light into usable, comfortable binocular vision. It is the part of the exam that most closely resembles classic optometric science, but expect it presented as clinical problems: a patient with a complaint, a set of findings, and a decision to make.
Refractive Conditions
Candidates must be able to recognize, differentiate and manage the refractive states and the clinical situations built around them.
- Interpreting refractive findings and deciding what correction or management fits the patient's visual demands
- Recognizing how refractive status connects to binocular function and symptoms
- Linking optical principles to what a patient actually reports, such as blur, asthenopia or fluctuating vision
Accommodative / Vergence / Oculomotor Anomalies
The outline's own wording is "Accommodative / Vergence / Oculomotor Anomalies," and that wording controls over the slightly different phrasing in the matrix. The substance is the same: the dynamic, focusing and eye-movement systems and what goes wrong with them.
- Distinguishing accommodative from vergence causes of the same symptom complaint
- Reading case data to identify the binocular diagnosis and the sensible management path
- Recognizing oculomotor findings that point beyond a functional problem toward something requiring further workup
Sensory Processes
Sensory processing questions test how visual information is received and integrated, and how disruptions show up in patient complaints and test results.
- Interpreting sensory findings within a case rather than as stand-alone facts
- Connecting sensory abnormalities to likely causes and next steps
Because the exam is case-driven, Domain 1 questions often hand you a presentation and expect you to move from findings to diagnosis to management in a few steps. Memorizing definitions will not be enough; you need to be comfortable reasoning from data. The PAM cheat sheet is a handy way to keep key reference points close while you build that reasoning skill.
Domain 2: Normal Health / Disease / Trauma
This is the heavyweight. At 60-70% of the examination, Normal Health / Disease / Trauma is where most of the score is decided. It spans recognizing normal ocular and systemic status, identifying disease, and managing both the common and the urgent presentations, including trauma.
Normal Health
Knowing what normal looks like is the foundation for spotting what is not.
- Distinguishing normal variation from early or subtle pathology
- Understanding which findings are benign and which warrant monitoring or referral
Disease
Expect the full breadth of ocular disease and the systemic conditions that affect the eye. Questions typically require you to identify the condition from a presentation and then decide on treatment or management.
- Diagnosing from history, signs and symptoms woven into a patient case
- Selecting appropriate therapy, including pharmacologic options, and knowing when to refer or co-manage
- Recognizing systemic associations that change management
Trauma
Trauma cases reward prioritization: what must be addressed immediately, what can wait, and what changes the plan.
- Triage and sequencing of care in injured patients
- Recognizing signs that indicate a sight- or health-threatening problem
Test day supplies an on-screen searchable list of generic and trade drug equivalents, but NBEO notes that list is not an exhaustive syllabus. Do not treat it as a promise of what will be tested, and do not rely on looking up a drug you have never studied. Know your therapeutic options well enough that the list merely confirms what you already recognize.
Key Takeaway
If you have limited study time, weight it toward Domain 2, but keep Domain 1 warm. A third of the exam is still a third of the exam, and functional-vision questions can be the ones that separate a comfortable pass from a close call. Compare this with the numbers in PAM Passing Score 2026 to see how small margins can matter.
The Content Matrix: Four Task Dimensions, Not Four More Domains
NBEO also publishes a separate Part II Content Matrix (the linked filename is dated May 4, 2026). This is where candidates often get confused. The matrix does not add four new domains to the two above. Instead, it cross-classifies the same content by the kind of thinking a question requires. Every item has a content area and a task type.
| Task dimension | Approximate range | What it tests |
|---|---|---|
| Clinical Correlation of Basic Science Principles | 11-17% | Applying foundational science to explain or predict clinical findings |
| Diagnosis | 26-34% | Reaching the correct diagnosis from case data |
| Treatment / Management | 40-57% | Choosing therapy, follow-up, referral or co-management |
| Legal Issues / Ethics / Public Health | 4-10% | Professional, legal, ethical and population-health considerations |
These ranges should be read as published, without adjusting them so they add to exactly 100. Clinical Presentation (history, signs and symptoms) is assessed within the cases themselves and does not carry its own separate percentage.
For a broader conceptual overview of what the exam measures and why, see What Is PAM? and the shorter explainer What Does PAM Stand For?
How the Domains Appear on Test Day
The domain structure only makes sense once you see how it is delivered. The full examination has 350 questions in two sessions of 175, with seven testing hours in a single day, split into two 3.5-hour sessions. The morning session includes an additional 15 minutes for the tutorial and non-disclosure agreement, and an optional break of up to 45 minutes separates the sessions. Those extras are not question-timer minutes.
Case-Based Items
Image-intensive patient cases generally have three to six associated items, with three to ten response options each. That means a single clinical scenario, often with photographs or diagnostic images, feeds several questions that probe diagnosis, then management, then related reasoning. Domains blend within a case: a patient might present with a functional complaint in Domain 1 territory and reveal a health finding that belongs to Domain 2.
Single-Answer and Multiple-Response Questions
Both formats appear. On multiple-response items, up to four correct selections can be required, and you earn credit only by selecting all and only the requested correct options. That rewards precise knowledge over educated guessing, and it makes partial recognition risky. When you practice, train yourself to commit to a complete set of answers rather than hedging.
TMOD Items Embedded in the Exam
Approximately 120 TMOD items are embedded within the 350, not added to them. Overall PAM and TMOD receive separate pass/fail decisions. The count is qualified as approximate in NBEO's outline and program description, so do not treat 120 as an exact figure. Standalone TMOD is a separate registration pathway and is not the same as taking the full PAM examination.
Tools and Constraints
- The exam is closed-book.
- An on-screen basic calculator, a searchable generic/trade drug equivalence list, an abbreviation list and a supplied scratch booklet are available.
- Session 1 cannot be revisited after the inter-session break.
- Unscheduled breaks do not stop the clock.
The no-return rule for Session 1 is worth planning around. Use your time in the morning to answer carefully, since you will not be able to go back after the break.
Sequencing Your Preparation by Domain
Rather than a generic schedule, tie your calendar to the domain weights. The idea is to front-load the largest, most management-heavy content and to revisit functional vision regularly so it does not fade. A fuller approach is laid out in the PAM Study Guide; the outline below shows how the domain weights can shape it.
Domain 1 foundation
- Rebuild refractive and binocular reasoning from findings to diagnosis
- Work accommodative, vergence and oculomotor cases, using the outline's wording as your topic list
Domain 2 core
- Cover normal health, disease and trauma, always pairing each diagnosis with its management
- Practice multiple-response items where several options must all be correct
Integration
- Take mixed, image-based case sets that blend both domains
- Review Treatment / Management reasoning, ethics and public-health items
Domain 2 gets the longest block because it carries the most weight, but the final weeks mix everything, since the real exam does. NBEO also offers an optional Part II PAM/TMOD Practice Databank with NBEO-owned questions, administered by independent third party Test Run. It costs $199 for one month, with a $149 additional-month renewal subject to registration and administration-date conditions. These are preparation charges, separate from the exam fee, and neither buying nor completing the databank guarantees a pass. This guide has not accessed the paid bank, so evaluate it on your own needs.
Registration, Fees and Scoring Context
Knowing the domains is only part of readiness. You also need to handle the mechanics. You register and pay through NBEO, then schedule your appointment with Pearson VUE at a testing center in the USA, Puerto Rico or Canada. The exam fee is $1,490 for administrations beginning August 2026, and late registration adds $400. For the broader picture of expenses, see PAM Certification Cost, and for timing and deadlines see PAM Exam Dates.
Eligibility generally begins in the academic year of graduation from a program accredited by ACOE with Accredited, Accredited with Conditions or Preliminary Approval status, with institutional confirmation. Other candidates need direct sponsorship from a qualifying optometric program or a state optometry licensure board. The details are in PAM Requirements. Bring two current signed physical IDs, at least one a government photo ID, matching your registration.
How Scoring Works
NBEO's Scoring & Reporting page uses a 100-900 scale and states that scores above 300 pass. That wording should be kept exactly as stated rather than converted into a raw percentage. Scores are equated across forms, not curved, so your result reflects performance against a fixed standard instead of against other candidates on your test day. After six attempts, special approval or remediation is required. NBEO prohibits recalled-item distribution and superscoring.
What the Pass-Rate Figures Do and Do Not Say
Two published figures are easy to confuse. UC Berkeley and Ferris State both report an 89.4% national first-time Part II PAM pass rate for academic year 2025-2026 (September 1-August 31). Separately, NBEO's Institutional Yearly Performance Report for October 1, 2024-September 30, 2025 reports an 87.96% Part II first-time pass rate for a cohort of 1,628 qualifying U.S. graduates who attempted all three NBEO parts at least once. These cover different populations and different periods, so they should not be pooled or read as a trend. For more context, see PAM Pass Rate 2026.
Frequently Asked Questions
The Part II PAM Content Outline has two top-level domains: Refractive / Sensory Processes / Oculomotor Processes (30-40%) and Normal Health / Disease / Trauma (60-70%). The separate content matrix adds four task dimensions that cross-classify the same material rather than creating more domains.
Normal Health / Disease / Trauma, since it makes up 60-70% of the exam. Because Treatment / Management is the largest task dimension at 40-57%, pair every condition you study with its management approach. Keep reviewing Domain 1 so it stays fresh.
No. Clinical Correlation of Basic Science Principles (11-17%), Diagnosis (26-34%), Treatment / Management (40-57%) and Legal Issues / Ethics / Public Health (4-10%) describe the kind of reasoning each question demands, applied across both domains. Clinical presentation is assessed within cases and has no separate percentage.
No. The on-screen searchable generic/trade drug equivalence list is a convenience tool, and the drug list is not an exhaustive syllabus. You still need to know therapeutic options and when to use them before test day.
NBEO's current Scoring & Reporting page uses a 100-900 scale and says scores above 300 pass. Scores are equated across forms rather than curved. For a closer look, read PAM Passing Score 2026.
Mastering the two domains, and the task types that run through them, gives you a clear map of what the exam asks. Use that map to direct your hours, and test yourself against realistic case sets on the PAM Exam Prep practice site as your preparation progresses.